Special Event Application

Special Event Application

For Single Events
Click here for Insurance Terms & Definitions.
APPLICANT INFORMATION
How did you hear about us?*
Select how you found our website.
What coverages do you require?*

General Liability (Required)Liquor LiabilityRented EquipmentAuto CoverageParticipant MedicalWorkers Compensation
Insured Name*
The name of your production company or entity (or individual name if not incorporated) you would like to insure. Use the same name as on your rental quote.
Entity Type*
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

Confirmation Email
Website
Description of your operations:*
Federal Tax ID or Social Security Number May Be Required if obtaining Workers Compensation*

I Understand

EVENT DETAILS
Select the type of event:*

Wedding/PartyMusic/Concert EventSporting EventRetreat/Overnight EventOther
Event Start Date*

MonthDayYear
Date
Event End Date*

MonthDayYear
Insurance exp. is 12:01am. If your last day or filming is April 25th use April 26th as the last day of coverage (as it will expire on 04.26 12:01am).
Event Name*
Venue Name*
Venue Address*
Rehearsals Address
If different from the venue location.
Event Description*
Event Website URL
Budget*
Anticipated Gross Revenue
Event will be held:*

IndoorsOutdoorsBoth
Maximum Daily Attendance*
Total Attendance*
Number of Participants/Performers*

General Liability

General Liability covers payments the insured will become legally obligated to pay as a result of Bodily Injury or Property Damage arising out of an occurrence during live events, performances, etc. Applies to third parties, excluding your own cast and crew, location. Injury to your own cast and crew can be covered under workers compensation, if selected. If you would like a quote with workers compensation a separate application is be required.
Please select a General Liability limit:*
Damage To Rented Premises*
Do you require a waiver of subrogation?*

YesNo
Who is requiring the waiver?*
What is their involvement in the event?*

Rented Equipment
Rented Equipment Replacement Value:*
What type of equipment is being rented?*
Will the property be stored overnight?*

YesNo
Please provide details on how it will be stored:*
Will the Insured be responsible for transporting the property?*

YesNo
How will it be protected from damage during transport?*
Who is transporting the property?*
Is the company transporting the property naming the Insured as Additional Insured on their Insurance policy?*

YesNo
Will the property stay in the possession of the Insured at all times prior to returning to rental company?*

YesNo
Please explain:*
Which equipment rental houses are you using?*

Workers Compensation

Covers medical injury to your hired cast or crew. This may include W2 employees, 1099 freelancers & volunteers. Available in most states.
Worker’s Comp limit of $1,000,000*

IncludeExclude
Waiver of Subrogation

IncludeExclude

	Part Time	Full Time
Number of Employees

Additional Information, Comments
Additional Information or Comments, if necessary, can be provided.
Would you like to receive our quarterly newsletter?*

YesNo
NY License # BR-1001302

CA License # 0I36156 - dba in CA as New York Film Emporium Insurance Services
Should be Empty:

UNDERWRITING QUALIFICATION QUESTIONS

	Name	Street Address	City	State	Zip Code
Entity #1
Entity #2